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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: j .� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> R APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 24 q 9tyP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y-,aZ-,2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862/ and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` '.f I CENSUS TRACT <br /> Owner's Name Phone y�y� <br /> Address l ! l City <br /> Contractor's Name License 0-le Phone <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPE14 / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION A7 PUMP REPAIR / / PUMP REPLACEMENT /,7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal <br /> PUMP INSTALLATION: Cgntractor <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: / / State Work Done 7 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AokA INAI, I PECTION. <br /> SIGNED TITLE <br /> :�(DRAW <br /> POT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />